Randomised trials of secondary prevention programmes in coronary heart disease: systematic review

Objective To determine whether multidisciplinary disease management program mes for patients with coronary heart disease improve processes of care and reduce morbidity and mortality. Data sources Randomised clinical trials of disease management programmes in patients with coronary heart disease were identified by searching Medline 1966-2000, Embase 1980-99, CINAHL 1982-99, SIGLE 1980-99, the Cochrane cont rolled trial register, the Cochrane effective practice and organisation of care study register, and bibliographies of published studies. Data extraction Studies were selected and data were extracted independently by two investigators, and summary risk ratios were calculated by using bot h the random effects model anti the fixed effects model. Data synthesis A total of 12 trials (9803 patients with coronary heart dise ase) were identified. Disease management programmes had positive impacts on processes of care. Patients randomised to these programmes were more likel y to be prescribed efficacious drugs (risk ratio 2.14 (95% confidence inter val 1.92 to 2.38) for lipid lowering drugs, 1.19 (1.07 to 1.32) for beta bl ockers, and 1.07 (1.03 to 1.11) for antiplatelet agents). Five out of seven trials evaluating risk factor profiles showed significantly greater improv ements with these programmes in comparison With usual care (with effect siz es in the moderate range). Summary risk ratios were 0.91 (0.79 to 1.04) for all cause mortality, 0.94 (0.80 to 1.10) for recurrent myocardial infarcti on, and 0.84 (0.76 to 0.94) for admission to hospital. Five of the eight tr ials evaluating quality of life or functional status reported better outcom es in the intervention arms. Only three of these trials reported the costs of the intervention-the interventions were cost saving in two cases. Conclusions Disease management programmes improve processes of care, reduce admissions to hospital, and enhance duality of life or functional status i n patients with coronary heart disease. The programmes' impact on survival and recurrent infarctions, their cost effectiveness, and the optimal mix of components remain uncertain.